To Alma Roberts, Maryland's grim statistics on infant mortality affect more than babies. They serve as an indicator of the state's overall health. And she's alarmed.
Maryland has struggled for a decade with infant death rates above the national average - it ranked 31st in 2005 statistics - and figures released last month showed the problem getting worse. In 2007, the infant mortality rate increased, and the racial disparity in infant deaths widened. Last year, 14 newborns died per 1,000 live births, and black infants were three times as likely as white infants to die within their first year.
"This is huge," said Roberts, president and CEO of Baltimore Healthy Start, a nonprofit that seeks to combat racial disparities in infant deaths. "Infant mortality is one of the most sensitive indicators of the health of a community, and here is Maryland totally out of line with the nation."
In response to the latest data, state and local medical officials, community advocates and health care providers are planning an assault on the complex problems concerning infant health.
Years ago, the medical community combated infant mortality by simply pushing for more access to prenatal care, which is considered vital for healthy birth outcomes.
Now, officials are calling for that and then some, including emphasizing the importance of women's health before conception, examining patient safety in hospitals statewide and investigating whether facilities are equipped to handle high-risk pregnancies. Health experts are also pushing for the expansion of community-based efforts such as Healthy Start, which recently launched an awareness campaign called Cradle of Hope during a rally in Baltimore.
"We are looking at rethinking the whole approach," said Dr. Joshua M. Sharfstein, the city health commissioner. "There are limits to what prenatal care can accomplish, and for many it's coming so late. The health of the mother before she becomes pregnant is so critical to a successful pregnancy."
Leigh Cobb, health policy director for Advocates for Children and Youth, called the racial disparities "appalling" and the overall mortality figures, "shameful." While health experts are vexed by the factors that contribute to poor birth outcomes and racial disparities, they must confront them in new ways, she said.
Some factors contributing to infant mortality have been well-known for years. For instance, prematurity and low birth weight are the best predictors of danger to infant survival. But medical experts are giving attention to other factors as well, including poverty, psychological stress, pre-existing health conditions, substance abuse, nutrition, the father's role, maternal age and the critical time between pregnancies known as the "inter-conceptional period."
Thirty percent of women who have a bad birth outcome are likely to have a second, said Cobb.
"What we need to do is target these women and make sure they are healthy before they have another child," she said. "We know who these women are. So there is an opportunity to help this."
Advocates hope a recent expansion in publicly funded health insurance will help poor women receive preventive care. In July, the state expanded Medicaid access to include parents with incomes up to 116 percent of the federal poverty line - about $20,500 for a family of three.
Before the new guidelines, parents earning up to 40 percent of poverty were eligible. Women too poor to qualify went without health care until they became pregnant. Even then, it could take weeks to navigate the paperwork and referral process.
For others, coverage came too late, experts say. One in five Maryland women who give birth does not receive prenatal care, according to state figures.
Providing better health care is important, but to help these women stay healthy, their communities must be healthy, said Cobb. That means supportive environments free from violence and with access to nutritious food, she said.
In Baltimore, such conditions can be tough to find in low-income communities, said Roberts of Healthy Start, whose advocates blanket entire communities providing education, parenting advice, even food and furniture.
"We work with women on their diet and about good nutrition," she said. "We talk about it, but there are no grocery stores in Sandtown-Winchester. That's part of the problem."
Still, even though 98 percent of Healthy Start's clients are African-American and live in some of Baltimore's most impoverished communities, the organization has made great progress in decreasing infant mortality rates and low-weight births. In 2007, 11.3 infants died per 1,000 births in Baltimore, while Healthy Start's clients had an infant mortality rate less than half that figure.
This summer, the organization began a pilot program called "Belly Buddies" designed to help women in the vital "inter-conceptional period" learn to support one another. In addition to the home visits and counseling that Healthy Start clients receive, the program urged the women to build support networks through yoga classes and knitting circles.
Keisha Elliott, 24, joined the eight-week program in May and said it made all the difference in her pregnancy. During her first pregnancy four years ago, she suffered health problems. She was diagnosed with pre-eclampsia; her son, Tyronn, was born early at 35 weeks. Two weeks ago, Elliott gave birth to a healthy daughter, London, whom she carried to term.
In Belly Buddies, she learned about proper nutrition and how to manage stress, even during a bitter custody battle with Tyronn's father. Most important, she built lasting bonds with fellow members.
"This has really been a sisterhood for me," she said. "I have learned how to cope, and how to deal with people in a different way. The people at Healthy Start would do anything for me. And I knew they were just a phone call away."